Burnout among healthcare providers: Its prevalence and association with anxiety and depression during the COVID-19 pandemic in Macao, China

Introduction Burnout in healthcare providers (HPs) might lead to negative consequences at personal, patient-care and healthcare system levels especially during the COVID-19 pandemic. This study aimed to investigate the prevalence of burnout and the contributing variables, and to explore how, from health workforce management perspective, HPs’ experiences related to carrying out COVID-19 duties would be associated with their burnout. Methods A cross-sectional, open online survey, informed by physical and psychological attributes reportedly related to burnout, the Copenhagen Burnout Inventory (CBI) and the Hospital Anxiety and Depression Scale (HADS), was completed by HPs in Macau, China during October and December 2021. Factors associated with burnout were analysed using multiple logistic regressions. Results Among the 498 valid responses, the participants included doctors (37.5%), nurses (27.1%), medical laboratory technologist (11.4%) and pharmacy professionals (10.8%), with the majority being female (66.1%), aged between 25-44years (66.0%), and participated in the COVID-19 duties (82.9%). High levels of burnout (personal (60.4%), work-related (50.6%) and client-related (31.5%)), anxiety (60.6%), and depression (63.4%) were identified. Anxiety and depression remained significantly and positively associated with all types of burnout after controlling for the strong effects of demographic and work factors (e.g. working in the public sector or hospital, or having COVID-19 duties). HPs participated in COVID-19 duties were more vulnerable to burnout than their counterparts and were mostly dissatisfied with the accessibility of psychological support at workplace (62.6%), workforce distribution for COVID-19 duties (50.0%), ability to rest and recover (46.2%), and remuneration (44.7%), all of which were associated with the occurrence of burnout. Conclusions Personal, professional and health management factors were found attributable to the burnout experienced by HPs during the COVID-19 pandemic, requiring actions from individual and organizational level. Longitudinal studies are needed to monitor the trend of burnout and to inform effective strategies of this occupational phenomenon.


Introduction section
Burnout has been shown in studies to be common in HPs, and it is closely related to anxiety and depression, according to the authors (line 73-78). Given the high prevalence of burnout in HPs, which has been linked to anxiety and depression, the question here is, what gaps will be addressed in this study, and what makes this study unique? What new body of knowledge has been added to the global community? The rationale What are the gaps that need to be filled, and what makes it unique? This is not convincing and should be demonstrated clearly.

Response:
Thank you for the comments. Major revisions have been made to the Introduction section to highlight the research gaps, the rational of this study, and the new knowledge to be generated from this study findings.

Methods sections 2.1 Study design -The study design should be rewritten succinctly --too much information
Response: Thank you for the comment. Major revisions have been made to the Methods section accordingly.

2.2
The study design should explain why a survey is the best method of data collection for the study.

Response:
Thank you for the comment. For the purpose of this study, a survey research design allowed data collection to be completed in a relatively short period so that a snapshot of the burnout phenomenon among HPs during the non-acute phase of the COVID-19 pandemic could be depicted in a timely manner amid the continuous progress of the situation. Such information has been added to the first paragraph of the section of Materials and methods.

The statement regarding ethical consideration is also included in the study design section and is
suggested to be separate and placed at the end of the method section.

Response:
Thank you for the comment. The statement regarding ethical consideration has been moved under the subsection of Data collection in the Materials and methods section.
2.4 Study setting and target population -The target populations were all Macao-based HPs. But who exactly are the HPs? Response: Thank you for the question. We have added the following information to the subsection of Study target in the Materials and methods section.
"The target population of this study was all the HPs practicing in Macao such as doctors, nurses, pharmacists, medical laboratory technologists, Traditional Chinese Medicine doctors, etc." On the other hand, the professional categories of the participants were also listed in Table 1  Thank you for the question. Participants' workplace information (e.g. public sector or non-public sector; hospital setting or non-hospital setting) was provided in Table 1 in the original manuscript ( Table 2 in the revised manuscript).
2.6 Are healthcare providers registered with the Health Bureau in Macau as of 2020 but not practicing or living in Macau included or excluded from the study?? Response: Thank you for the question. As stated in subsection of the Questionnaire design in the Materials and methods section in the original manuscript, the first question in the questionnaire was for the respondents to confirm whether they were HPs practicing in Macao. Only those who had confirmed their place of practice being in Macao were included in this study.
In addition, in order to improve clarify, "All respondents confirmed that their place of practice was in Macao." has been added to the second paragraph of the Results section.
2.7 All this suggest that the target population be clearly defined by clearly indicating who is included and who is excluded.

Response:
Thank you for the comment. We hope that above responses would be deemed sufficient to address the concern.
2.8 Sampling methods and size -The author simply stated 371 as a minimum sample size, but the sampling techniques used to select the sample are unclear --suggest that the sampling methods used to select these observational units be described.

Response:
Thank you for the comment. Convenience and snowballing sampling method was employed in this study.
Such information has been added to the subsection of Data collection in the Materials and methods section.
2.9 Furthermore, a contradictory statement is written at the beginning of the methods sections: "open and online survey to be completed voluntarily by healthcare providers in Macao between October and December 2021." (line 102) Respondents who had completed the COVID-19 duties were invited to complete the Section 4 questions. This section was created to investigate HP's perception of health workforce management during the COVID-19 pandemic and to identify areas where improvements could help to mitigate burnout (line 192-194) • Are these study participants distinct from the 371?
• How many of these took part?
• How were these participants chosen to respond to Section 4? Response: Thank you for the question. The following clarification is provided for your kind re-consideration. As stated in the original manuscript, • According to Line 132-133, "371" was only referring to the minimum sample size calculated for the current study (confidence level 95%, margin of error 5%).
• According to Line 261-264, "A total of 622 people visited the survey link, of which 616 gave consent to participate, giving a participation rate of 99%. Out of the 616 respondents who agreed to participate and attempted the survey, 498 surveys were completed, giving a completion rate of 80.8%." Indeed, 498 respondents were included in this study (Section 1 to 3).
• As reported in Table 1 in the original manuscript ( Table 2 in the revised manuscript), among the 498 respondents, 413 had been involved in COVID-19 related professional duties • According to Line 331, "Among 413 respondents who had participated in the COVID-19 related duties, 396 opted to continue into Section 4 of the questionnaire.." We hope that the clarification above would be deemed sufficient to address the concern.
2.10 The author gathers data through volunteerism (volunteer sampling) and snowballs sampling. These approaches, commonly known as convenience sampling, have the lowest credibility of any sampling method and should only be used as a last resort.

Response:
Thank you for the comment. We agree that selection bias and response bias are inevitably given the nature of the data collection approaches. In the Limitations section of the original manuscript, we acknowledged such shortcomings. In the revised manuscript, we have also added "Bias towards potential volunteerism might have also inevitably increased sampling error, affecting the generalizability of the study findings and restricting the inference made about the entirety of the HP population." to emphasize the impact of such shortcomings.
2.11 Analysis -the reason /assumption why using Spearman's rho test are not justified

Response:
Thank you for the comment. We would like to clarify that Spearman's rho was used in Table 5 as shown in the original script considering that as Spearman's rho is recommended for reporting correlations related to Likert scale items and a non-parametric measure of rank correlation could not be ruled out. We have revised the subsection of Data analysis accordingly to better indicate this.

Result
3.1 The number of study participants reported in the results section is inconsistent with the calculated sample size (377) vs actual participation (498).

Response:
Thank you for the question. The following clarification is provided for your kind re-consideration. As stated in the original manuscript, • According to Line 132-133, "371" was only referring to the minimum sample size calculated for the current study (confidence level 95%, margin of error 5%).
• According to Line 261-264, "A total of 622 people visited the survey link, of which 616 gave consent to participate, giving a participation rate of 99%. Out of the 616 respondents who agreed to participate and attempted the survey, 498 surveys were completed, giving a completion rate of 80.8%." Indeed, 498 respondents were included in this study (Section 1 to 3).
We hope that the clarification above would be deemed sufficient to address the concern.
3.2 Logistic regression analysis -There is no evidence that the authors checked logistic regression assumptions (such as the assumption of collinear relationships among explanatory variablescorrelation of |r|, VIF value, etc.) before using the fitted model to infer the relationship between the response variable and the explanatory variables.

Response:
Thank you for the comment. Before we ran the logistic regression analysis, an analysis of standard residuals was carried out, which showed that the data contained no outliers considering standard residual minimum = -2.435, standard residual maximum = 2.215 for personal burnout; standard residual minimum = -2.241, standard residual maximum = 2.087 for work burnout; and standard residual minimum = -1.75, standard residual maximum = 2.214 for personal burnout (standardized residuals beyond ± 3 are usually considered to have outliers).
On the other hand, tests conducted to check if the data met the assumption of collinearity showed that multicollinearity was not a concern considering tolerance >0.1 and variance inflation factor (VIF) <5 for all 15 independent variables (considering that only VIF greater than 5 or 10 are usually suggested for detecting multicollinearity). More specifically, all the VIF ranged from 1-2.5 except for age (VIF 4.814) and years of practice (VIF 4.600). The slightly higher VIF for age and years of practice is understandable considering that, in general, the older the participant was, the longer he or she would have practiced. for client-related burnout). Tests were also conducted to show multicollinearity was not a concern for the 15 variables (including demographic and professional characteristics, as well as anxiety and depression status) considering that tolerance for all the variables was greater than 0.1 and none of the variance inflation factor (VIF) was greater than 5." Thank you for the comment. The OR shown in Table 5 was the unadjusted odds ratios using a reference category. To improve clarity, the following has been added to the manuscript.
"The unadjusted odds ratios indicated that: (1) HPs in the public sector were 2.088 (95% CI 1.160-3.758) times more likely to experience moderate to severe personal burnout compared to HPs in non-public sector; (2)  Thank you for the comment. The reference category for each independent variables has been added to Table 5.
3.5 Logistic regression analysis, such as OR and CI, is not interpreted. Response: Thank you for the comment. As responded above to comment 3.3, additional interpretation has been added to the manuscript.

the direction and the strength of correlation is not mentioned
Response: Thank you for the comment and we agree that we can further interpret the direction and the strength of correlation reported in Table 6. As such, we have added the following to the subsection of HPs' experiences with COVID-19 related duties: "Spearman's correlation was computed to assess the relationship between the level of agreements on the experiences with COVID-19 related duties to the likelihood of moderate to severe personal, work-related, and clientrelated burnout. Apart from statements 1 and 3, all the other statements were negatively associated with burnout.

Strength and limitation
Response: Thank you for the comment. Major revisions to the Discussion section have been made accordingly.

Conclusion and Recommendation
Response: Thank you for the comment. Major revisions to the Discussion section have been made accordingly.
1. Overall, this is an excellent article and very well written. The impact of COVID-19 on health and care workers is possibly one of the key public health issues of our time, with potential consequences that can reverberate for the next few years and decades. I would like to congratulate the authors for such a well developed and comprehensive paper that examines burnout and various determinant of burnout among HPs. Response: Thank you for the encouraging comment. https://www.who.int/publications/m/item/impact-of-covid-19-on-human-resources-for-health-andpolicy-response--the-case-of-belize--grenada--and-jamaica). Burnout has been highlighted as one of the impacts in the mental health dimension of the framework. So it would be ideal to include a citation for the multidimensional framework, just to sensitize the readers that burnout is just one of the multitudes of impacts of the pandemic on HPs. Response: Thank you for the encouraging comment. We have added this important information and quoted the WHO document in the Introduction section.